Provider Demographics
NPI:1215182365
Name:MIEDEMA, JENNIFER M
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:MIEDEMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 CHARLES REISS RD
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-3369
Mailing Address - Country:US
Mailing Address - Phone:845-649-6216
Mailing Address - Fax:
Practice Address - Street 1:68 CHARLES REISS RD
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-3369
Practice Address - Country:US
Practice Address - Phone:845-649-6216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006494-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist